Lecture of Psoriasis

2021-03-24 12:00 AM

Under the influence of pathogenic factors (triggers, environmental factors) such as stress, infection, mechanical injury, physical trauma, endocrine disorders, drugs

Outline

Psoriasis (psoriasis) is a chronic, common, and frequent skin disease. In the European and American countries, the incidence of psoriasis accounts for 1-2% of the population. In Vietnam, the psoriasis rate is 5-7% of the total number of dermatological patients who come to the dermatology clinics.

Etiology - pathogenesis of psoriasis has been studied for a long time, but there are still many unclear points, today it is thought that psoriasis is an inherited skin disease, the gene that causes psoriasis is located on chromosome 6. Related HLA- DR7, B13, B17, B37, BW 57, CW6 ...

Under the influence of pathogenic factors (triggers, environmental factors) such as stress, infection, mechanical injury, physics, endocrine disorders, drugs ... this gene is activated. to epithelial hyperplasia produces psoriasis.

Psoriasis is an immunomodulatory disease, the role of activated T lymphocytes, cytokines, IGF1, EGF, TGF, IL 1, IL 6, IL 8, the chemical mediating group eicosanoides, prostaglandine, plasminogen that result ultimately leading to epidermal cell proliferation and psoriasis-producing cockroaches.

The main clinical features are monolithic rashes, red patches of different sizes (from a few millimeters to tens of centimeters) on the skin, stains, infiltrates, white scaly surfaces like candles, areas resident in an area or scattered throughout the head, body, arms and legs. Symptoms of itching account for about 20-40% of cases. The disease usually occurs most in the age group 10-30, the proportion of men and women is approximately the same.

Progression is chronic, almost lifelong but benign, with the exception of a few serious ones, which can lead to complications such as joint psoriasis, systemic erythematous psoriasis, exacerbations in remission. The quality of life is reduced, the disease affects psychology, activities and aesthetics much.

Treatment of psoriasis is still difficult, there are many drugs and many methods being applied, but none of them can be completely cured. recurrence, some drugs have many toxic and expensive side effects ... so it is necessary to explain clearly to the patient about the disease to have a good cooperation, and after the treatment of the disease is better or temporarily recovered , should be given to the patient maintenance therapy regimen and prevention of recurrence.

Aetiology - pathogenesis

Aetiology - pathogenesis still has many unclear points, but most authors consider psoriasis hereditary skin diseases, genetic skin diseases. The genetic factor is recognized, under the influence of triggers (such as stress, infection, physical mechanical injury ...) the gene that causes psoriasis is activated and produces psoriasis. candle.

The gene that causes psoriasis is located on chromosome number 6 and is related to HLA, DR7, B13, B17, BW57, and CW6.

Genetic factors account for 12.7% (according to Huriez) and 29.8% (according to Bolgert), genetic predominance of 60% penetration.

Stress (stress) is related to onset and prosperity, patients with psoriasis of the nervous type are easily irritated, or anxiety ...

Infectious factors: the role of localized foci related to the development and development of psoriasis (rhinitis, tonsillitis, ...), mainly the role of streptococcus. The role of the virus, RNA virus with reverse transcription enzymes to create an abnormal immune complex has not yet been agreed.

Physical mechanical trauma: has a role in the onset of the disease (14%).

Metabolic disorder. Supposed to have disorders of sugar and protein metabolism.

Endocrine disorders: the disease is usually mild during pregnancy, but after delivery, it recurs or worsens.

Metabolic disorders on the skin: psoriasis skin oxygen utilization index increases significantly, sometimes more than 400% compared to normal skin, (in acute dermatitis only increases by 50-100%), this is a feature large (according to Charpy).

Cockroach fecal activity and DNA synthesis of the basal layer increased 8 times, proliferation of epithelial cells, especially the basal layer and dendritic layer leading to disturbances in the keratinization process (overkamen and subkeratosis). Normally epidermal turnover time (epidermal turnover time) is 20 - 27 days but in psoriasis skin this cycle shortens to 2 - 4 days.

Psoriasis is a disease with an immune mechanism, a lot of T-lymphocytes enter the damaged skin, TCD 8 cells are in the epidermis, TCD4 cells are in the dermis, leukoplakia. polymorphonuclear bridge from papillary to epidermis, role of several cytokines, IGF1 in epidermal growth, transmission of mitotic signals in psoriasis, EGF, TGF involved in growth and differentiation. keratinocyte, the role of IL1, IL6, IL8, the chemical intermediary group eisaconoides, prostaglandins, plasminogen, the role of T lymphocytes activating, increasing lymphokines, increasing epidermal proliferation, activating the desquamation process candle.
Increased levels of IgA, IgG, and IgE in the blood in psoriasis patients, progression, appearance of immune complexes, reduction of complement C 3

Psoriasis skin appears antibodies to the horny layer, which is a type of IgG, an anti-nuclear factor.

clinical

Location of injury

The lesions mostly appear first in the scalp (51% according to Huriez) and the pressure area (both elbow, knee, sacrum), localized or scattered in many places, sometimes all over. body, usually symmetrical in nature, with more extensive lesions on the extensor face.

Basic injury

The basic lesion of psoriasis is red - psoriasis.

Red plaques vary in size and size by a few millimeters - a few centimeters, sometimes tens of centimeters (large plaques entrenched in several positions), well-defined, somewhat tall, hard ground, infiltration (inflammation , indurated) more or less, sometimes the white scale covers most of the red background, leaving only the surrounding red border wider than the scale. Number of clumps: a few clusters to several tens, hundreds of lesions depending on the field

Scales cover the red cloud background, the scales are milky white, slightly glossy like mother-of-pearl, like white candles. Scaly many layers, easy to flake, when scraped into white powder, like chalk, like candle stains, scattered. Scales regenerate very quickly, peeling off one layer after another. The number of scales is much.

Ko'bner phenomenon (Ko'bner's phenomenon) can be called the phenomenon "trauma called injury", is common in proliferating psoriasis, which in many cases psoriasis lesions grow right on the scar, the scar. skin scratches, incisions, vaccinations ... 

To contribute to the diagnosis of psoriasis, in the past, it was often done a method called the Brocq method (Grattage de Brocq), using a scalpel or curling lightly many times, slowly on the surface of the lesion will times. Hit detects the following signs:

Candlestick sign: scrape off like white powder.

Signs that pellicule décollabé continues to shave will come a thin, tough, transparent film that can be peeled like onions.

The sign of blood dew (also known as the Auspitz sign), after peeling off the onion skin, reveals a red, blood-streaked skin like a small dewdrop, called a mark of blood dew.

Functional symptoms: itching is less or itchier, often itching more in the progression stage, itching symptoms 20-40% of the cases, some are not itchy but have a feeling of entanglement, aesthetic impact.

Nail damage is found in 25% of cases, foundation slabs have small indentations (such as seams' soles) or have longitudinal lines, or brittle, thick nails on the free shore, 10 nails being affected at the same time.

Scalp psoriasis is usually red plaques, white scales on the surface, often encroaching on the forehead into a rim called psoriasis, the hair still grows through the lesion, the patch is sometimes thick, scaly. sticky, red behind the ears, with cracks sometimes exuding, easily mistaken for oily skin, streptococcal cyanosis ...

Progression: chronic, almost lifelong disease, flare-ups in between remission episodes, benign illness, lifelong well-being, except for some severe forms such as arthropod psoriasis, erythema psoriasis Body.

Clinical forms

Droplet psoriasis (psoriasis punctata, psoriasis guttata)

Lesions are dots from 1-2 millimeters to several millimeters in diameter, floating scattered all over the body, especially the upper half of the body, bright red, covered with thin milky scales, easy to peel, scraped like chalk. This form is common in children and young people, the disease comes on suddenly, associated with streptococcal tonsillitis, otitis media, works well with antibiotic therapy, can resolve and resolve on its own, sometimes systemic skin redness due to inadequate treatment.

It is necessary to make a differential diagnosis with parotid psoriasis (with signs of total desquamation when scraping is called a cementus) and different from psoriasis II syphilis.

Psoriasis nummulaire (psoriasis nummulaire)

This is the most typical and common form, the patches are 1-4 cm in diameter, have a circular trend like coins, the number of clumps can be counted, several tens or more, progressing chronically. .

Psoriasis en plaques

This is a chronic form that has progressed for several years or more, is persistent in nature.
Usually large patches 5-10 cm in diameter or larger, localized in the pressure area (back, chest, sacrum, elbow, knee, front of shins), well-defined, thin patches more than others, the chest sometimes has a wide array like a wood, the shield of the medieval knight during battle.

Systemic red psoriasis (psoriasis erythrodermique exfoliative generalisée)

A severe, uncommon form (1% according to Goerkerman). The whole body is red, shiny, edema, infected, stretched, oozing, covered with wet scaly, no healed areas left, intense itchiness, erosive folds, pus-filled, chapped, painful burning.

Systemic symptoms: high fever, chills, gastrointestinal disturbances, gradual exhaustion can be fatal due to a certain infectious disease.

This form naturally progresses to a dropsy psoriasis or as a result of complications of inappropriate treatment such as an allergy DDS ...

Psoriasis arthropathique (psoriasis arthropathique)

Also known as psoriatic rheumatism, psoriatic arthritis (psoriatic arthritis). This is an uncommon form of heavy.

The vast majority of psoriasis lesions precede joint damage, skin lesions are often severe, diffuse, high scaly shells, sometimes combined with red skin psoriasis. Joint injury, type of chronic polyarthritis, rheumatoid arthritis, deformation. Swollen and painful joints, gradually go to deformity, limit movement, some fingers and hats are crossed like ginger branches, after many years become disabled, motionless, exhausted, and fatal due to complications. viscera.

Pustular psoriasis (pustular psoriasis)

A rare severe form, divided into 2 types:

Generalized pustular psoriasis (Zumbusch) was first described by Zumbusch in 1910. Appears as primary or in a patient with erythematous psoriasis or psoriasis (20-40%). Screening includes: sudden high fever, fatigue, skin with diffuse erythematous patches, pustular pustules with a diameter of 1-2 mm, burning sensation, later emerges a long, broad leaf flaking stage. For many weeks, hair loss, nail damage may occur, neutrophil counts are high, blood sedimentation increases, pus culture does not grow bacteria. The prognosis is generally good, or recurrent.

Pustular psoriasis on the palms of the hands, feet: body Barber (localized pustular psoriasis). Manifested by sterile pustules floating between the keratinous clumps of palms, feet, pustules progressing very persistent episodes, most common in female and little tissue, sometimes accompanied by edema of the extremities, high fever , inguinal lymph nodes, some cases turn into Zumbusch.

Reversed psoriasis

Psoriasis appears in the folds such as armpits, under-breast folds, navel, buttock folds, groin. Lesions are clearly limited red plaques extending beyond the interstitial site. Lesions can suddenly, cracks, accumulation of moisture, easy to mistake with candidiasis and interstitial interstitial streptococcus.

Psoriasis children

Usually at the age of growing, appearing after an inflammation of the upper respiratory tract, after vaccination ... the disease suddenly breaks down into dots, drops, thin scabs scattered all over the body, antibiotic treatment has a good effect.

Histopathology

Hyperkeratosis and parakeratosis (hyperkeratosis and parakeratosis): a markedly thickened layer of keratin, consisting of many layers of parenchymal cells (which are keratinocytes, which still have the nucleus remaining) between the keratinocytes with transverse slits filled with air. flake off.
Parenchyma is the result of hyper acanthosis, most of the papillary layer above the papillae is only 2-3 cell layers, but in the part of the papillary shoots that are hundreds of layers of cells, the germs are inter-papillae. it extends down to the dermis, the lower part is bulging like a drumstick, with branches sometimes sticking to the neighboring sprouts, the thorn layer and the basal layer show distinctly increased cockroaches.

The papillae are elongated upward and clubbed-shaped. The epidermis and the upper dermis are scattered with a number of inflammatory cells around the blood vessels including lymphocytes and cellular structure.

From the papillary and inferior capillaries, lymphocytes and polymorphonuclear leukocytes enter the interstitial spaces and the dendritic layer forms Munro micro-abscesses, which are important in histopathological diagnosis of psoriasis, often seen in new lesions, in the affluent stage.

Reduced skin pigmentation in the basal cell and papillary layers.

Dilated dermal capillaries.

Diagnose

Implementing the quadrants

Location.

Basic damage: red patches, hard background, covered with white scales many layers.

Ko'bner sign.

Brocq scraping method.

Histopathology of the skin.

Differential diagnosis

Asia psoriasis.

Gibert pink powder.

Asian streptococcus, eczematide.

Syphilis II.

Treatment

Treatment of psoriasis is still difficult, although new drugs and new, more effective treatments have been introduced in recent years, these drugs make the disease much better or temporarily cured. Once again, the disease recurred, there was no medicine to cure it completely.

Topical psoriasis medications

Medicines for psoriasis, tarpaulin:

Salicylic ointment 2%, 3%, 5% has the effect of peeling and combating the keratosis, reducing the symptom of desquamation but has no effect on the inflammatory symptom of infiltrating psoriasis.

Goudron: is a deoxidizer of 2 types.

Goudron source distillation angle decomposed from some sapwood (pine ...).

Goudron is derived from coal.

It was a dark brown or black liquid with a characteristic dark odor. Acidic pH, soluble in organic solvents, slightly soluble in water is used to treat psoriasis, eczema in alcohol solution, pastes, greases and pure (goudron pur).

Cade oil is a type of goudron derived from the distillation of a pine tree wood.

Coaltar is a type of coal goudron.

Goudron is a good classic psoriasis treatment, whose authors consider goudron the "king of topicals", applied to psoriatic lesions, causing scabs to dissolve and lesions disappear after. treatment course. The downsides are the black color, the stench of clothing, and some long-term use can cause folliculitis.
Sabouraud ointment is a well-known psoriasis treatment, consisting of goudron, cadmium, sulfur, resorcin ... a. salicylic.

Anthralin:

As a deoxidizer with the potential to inhibit the enzymes that regulate the use of red glucose is the enzyme 6-phosphate -deshydrogenase (G6-PDH).

Anthralin often used in the treatment of short contact (short contact).

In the first 2 weeks of daily application of Anthralin, the concentration of 0.1% - 0.3%, then 10-20 minutes of bathing and washing the drug.

The following weeks of treatment are maintained 2 times / week.

Pay attention to avoid skin irritation, do not take a hot shower after applying the drug within 1 hour, avoid putting the strap in the eyes.

Corticoid ointment (special pharmaceutical ointment Flucinar, Synalar, Eumovate, Betnovate, Tempovate, Diproson, Sicorten, Lorinden ...).

The advantage of corticoid ointment is that the disease is fast, relatively clean, and the patient likes it. The downside is that a wide area, long-term application can have side effects such as acne, skin atrophy, vasodilation, stretch marks ... and phenomenon "oily" or "shiny" after the disease recurs Worsening of the disease.

Currently, it is believed that the following corticosteroid ointment should be applied:

Apply a mild to moderate steroid fat type (groups IV, V, VI, VII).

Apply 1 batch of 20-30 days, then rest for a while if necessary, then use another batch.

Apply alternately, this time using corticoid ointment, the next time to apply another drug.

Avoid extensive application, prolong the day.

The mechanism of the drug is to inhibit the mobilization of polymorphonuclear leukocytes, inhibit DNA synthesis in phase G1, G2 of cockroach faeces, anti-inflammatory, anti-cockroach faeces.

Daivonex grease (calcipotriol):

It is a vitamin D3 analogue that inhibits keratinocytes and stimulates keratinocyte differentiation, acts on T lymphocytes, inhibits IL2 production, reduces the expression of HLA-DR, according to research data, it is better than corticosteroid ointment. It should only be used for local psoriasis, applied twice a day (morning and afternoon). Only apply less than 100 g / week, equivalent to applying 16% of the body surface area, usually better after 1-2 weeks, much better after 4-8 weeks of treatment. Do not apply the drug to the face, wash hands after applying, which can cause hypercalcemia or leave a long-lasting bruising, this drug is quite expensive.

Systemic medications for psoriasis

Photo chemotherapy:

PUVA therapy: PUVA therapy is the world-renowned treatment for psoriasis, and is widely praised in many countries as photochemotherapy.

This method was proposed by Parrish and Fitzpatrick in 1974.

The content of the method includes:

Take the light-inducing drug Psoralen.

2 hours later, a wave of ultraviolet A wave (UVA) at 320-400 nm (nanometer) was exposed.
The main effects of the PUVA method are:

Anti-mitotic effect.

The immunological effect reduces the number and activates T lymphocytes (TCD3, TCD4, TCD8), inhibits the synthesis of lymphoid DNA, reduces the kinetic factors, reduces IL2 production, and inhibits HLA DR expression of cells. keratinocytes.

Cleanses the lesion quickly, is effective during the period of prosperity and recurrence of the disease.

Simple, easy to do, avoid having to apply medicine.

Relatively safe, less toxic.

Attack phase 3 times / week for 1 month.

The period maintains 1 time / week for 2 months.

The results of many authors in many countries are 70-95% better after treatment with PUVA.

Side effects: some nausea, redness, itching, blistering, animals had some cataracts, cataract ...

Retinoids (etretinate group - the brand name Tigason-Soriatan):

Retinoid is a synthetic derivative of vitamin A that has a higher therapeutic effect and less toxicity than vitamin A, has anti-inflammatory properties (Antikeratisantes) and anti-neoplasm (Antineoplastique), the discovery of the group of Retinoids (Vitamin A). acid) is considered a "revolution" just like the invention of the drug cortocoid.

Chemical formula of etretinate:

Acitretine (Soriatan) has better pharmacological properties than etretinate (Tigason). The half-life at many doses is 50 hours, mainly excreted by the liver and little by the kidneys.
The mechanism of action of Retinoid is not completely clear, but it has the effect of regulating cell growth and differentiation, acting directly on the gene of keratin, slowing down epidermal proliferation and normalizing cell differentiation. Horn, immunomodulatory and anti-inflammatory epidermal infiltrates in psoriasis, inhibition of HLA class II expression (HLADR +)

Point:

Conventional psoriasis is extensive.

Psoriasis joints.

Body red psoriasis.

Psoriasis pustules.

Dosage:

The first week should be 10 mg daily, then gradually increase the dose 20-25 mg / day, when cheilitis is possible to achieve the maximum dose.

Take the drug for a few months to 6-12 months or reduce the maintenance dose to avoid relapse.

Side effects:

Conjunctivitis, dry eyes, dry skin (48-78%). 

Hair loss, itching, thin skin, inflammation of the lips (87-100%).

Dry mouth (8-88%), teratogenic in laboratory animals, so it should not be used in women of childbearing age (be sure before taking the drug, during use and after stopping the drug 2-3 months without pregnancy). Retinoids do not cause sperm mutations in men.

Methotrexate:

Methotrexate (MTX) is an immunosuppressant, a folic acid antagonist, has the effect of inhibiting the proliferation of nucleic acids, inhibiting the proliferation of epidermal cells in psoriasis, reducing inflammation. kinetics of polymorphonuclear leukocytes, reducing IL8 production in psoriasis. This drug is an inhibitor with the most harmful side effects, especially on the liver, so it is mainly used for diffuse plaque psoriasis and some severe forms such as joint psoriasis, systemic erythematous psoriasis, and facial psoriasis. width> 50% of body area and should mainly be used for healthy people 50 years of age and older, should not be used for the youngest of women of childbearing age or normal mild and moderate psoriasis.

Dosage and Administration:

According to Fitzpatrick 1997 time to use MTX in a 3-part regimen (Triple dose regimen).

Week 1 test dose: 2 MTX x 2.5 mg tablets, 12 hours apart, 1 capsule at 7:00 am, 1 capsule at 7:00 pm, test the blood count.

Week 2: 3 tablets of 2.5 mg 1/1/1 MTX. (For example, Monday morning: 1 tablet, Monday evening: 1 tablet, Tuesday morning: 1 pill, other days without medication).

Monitor how the disease lessens if needed next week, give 1-2-1 (Monday morning: 1 tablet, Monday evening: 1 tablet, Tuesday morning: 1 tablet, Wednesday morning: 1 tablet, other days) do not take medicine), and if the change is slow next week, give 2/2/2: Monday, Tuesday and Wednesday 2 tablets of MTX in the morning, 1 tablet of 2.5 mg in the morning, and 1 tablet of 2.5 mg in the evening. This dose of studies shows that 80% of patients get better before and after treatment, during the treatment of MTX once a month, they need to periodically check blood count, liver and kidney function (SGOT, SGPT, urea, creatinine ...) because MTX is a toxic drug, can cause leukopenia, platelets, accumulate in the liver causing degeneration or cirrhosis, favorable factors for miscarriage, teratogenicity, decreased sperm ...

Cyclosporin A (brand name Samdim mun, Samdimmun neoral):

Cyclosorin A is a cyclic polypeptide consisting of 11 selective immunosuppressive amino acids, used in organ transplantation for the prevention and treatment of graft rejection and disease, and also as a treatment for psoriasis.

Cyclosporin A is an immunosuppressive, reducing the T-lymphocyte activity in both the epidermis and dermis in the psoriatic region, having an indirect effect on vasodilation and epidermal hyperplasia as well as inflammatory cell activity. .

Point:

Severe psoriasis treated with conventional methods has not shown results.

Psoriasis pustules.

Psoriasis joints.

Contraindications:

There are malignancies.

Abnormal kidney function.

Uncontrolled high blood pressure.

Are taking other immunosuppressants, radiation therapy, chemotherapy.

Dosage:

2.5 mg / kg / day to 5.0 mg / kg / day orally divided into 2 divided doses (the most common dose is 4 mg / kg / day).

If clinical change occurs after 4 weeks, maintain that dose for another 6 weeks until the lowest effective booster dose. If after 6 weeks with a dose of 5 mg/kg, there is no result, discontinue the drug, consider the therapy has no results.

Do not exceed a maximum dose of 5 mg / kg / day.

After clinical improvement is acceptable to use a long-term maintenance dose (can be used for 2 years continuously).

Defect:

Expensive.

Hypertension occurs in 10.6% of patients.

Renal dysfunction, increased serum creatinine, during long-term therapy some patients may have changes in kidney structure (interstitial nephrosis).

There may be a number of other side effects such as hirsutism, tremors, liver dysfunction, fatigue, and enlarged gums.

Some other drugs

There are other medications that can be used in psoriasis treatment such as:

ACTH.

Barbiturates act on the central nervous system like bromide.

Vitamin A,C,B12, Biotin, vitamin H3.

Hypersensitivity, nonspecific anti-allergic: Calcium chloride, synthetic antihistamine.

General directions and strategies for psoriasis treatment

Before every psoriasis patient, careful consideration should be given to choosing a treatment that aims to achieve the following goals:

Clean the damage, make the disease much better.

Limiting recurrence (prolonging recurrence time).

Safety attention, less toxic.

Psoriasis is a chronic or recurrent but benign skin disease, mainly outpatient, and the patient needs to be instructed to become less and less dependent on the drug, and to explain it appropriately to the patient to avoid. Adverse factors can cause relapses and diseases such as nervous tension, micro-trauma ... know how to self-monitor and treat according to the periodic examination and guidance of a dermatologist.